Prophylactic antibiotics in chronic pediatric lung disease: balancing benefit, resistance, and future care models

INTRODUCTION: Children with chronic suppurative or inflammatory lung diseases, including cystic fibrosis (CF), non-CF bronchiectasis (NCFB), chronic suppurative lung disease (CSLD), and primary ciliary dyskinesia (PCD), experience recurrent infection and persistent neutrophilic airway inflammation that together drive progressive lung injury. Prophylactic antibiotic strategies have therefore been explored to interrupt this infection - inflammation cycle, encompassing both pathogen-specific approaches and longer-term anti-exacerbation or immunomodulatory therapies. AREAS COVERED: We review clinical trials, observational studies, and guideline recommendations evaluating prophylactic antibiotic use in chronic pediatric lung disease. A targeted literature search using PubMed was conducted, focusing on macrolide and non-macrolide prophylactic strategies in children under 18 years of age, disease-specific outcomes, antimicrobial resistance, and stewardship considerations across pediatric respiratory disorders. EXPERT OPINION: Evidence supporting antibiotic prophylaxis varies substantially by disease and clinical context. We propose a framework for selective, time-limited use of prophylactic antibiotics, emphasizing individualized risk - benefit assessment, regular reassessment of efficacy, and integration within antimicrobial stewardship paradigms.